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24A: Fitting and Training the Bilateral LowerLimb Amputee

Chapter24AAtlasofLimbProsthetics:Surgical,Prosthetic,andRehabilitationPrinciples
DouglasG.Smith,M.D.
ErnestM.Burgess,M.D.
JosephH.Zettl,C.P.

Thebilaterallowerlimbamputeehasthroughoutrecordedmedicalhistorypresenteda
specialchallengefortherehabilitationteamtoprovideadegreeofmobilitythatwouldallow
amorenormalplaceinsociety.Personswithhighlevelamputationsorcongenitallimb
deficitsthatpresentasimilarfunctionallosscanoccasionallywalkwithoutaprosthesisby
usingcrutchesandaswingthroughgait.Thisrequiresverygoodtrunkandupperbody
strength,senseofbalance,andmusclecontrol.Suchambulationisseenveryoccasionally
inchildrenandyoungadults.Inmostcases,assistivedevicesarenecessarytostandand
walk.Manysimpleaswellasingeniousmeanshavebeenusedbytheamputeetomove
fromplacetoplace.Oftentheamputeesselfdesignedandmadedevicesthatbestsuited
theirneeds.
Thesurgeon,theprosthetist,andtherehabilitationteamhaveattheirdisposaltodayawide
varietyofprostheticandassistiveaidsforprovidingcomfortablestandingandwalking.The
remarkabledegreeoffunctionalrestorationnowpossiblecanoftenpermitthebilateralleg
amputeetoparticipateinalifestylethatsociallyandvocationallyovercomeshisphysical
handicap.
Bilaterallowerlimbamputationsaremuchmorefrequentcurrentlythaninthepastlargely
secondarytoanagingpopulationwithanincreasedincidenceofperipheralvascular
diseaseanddiabetesmellitus.Improvedmedicalmanagementiscontinuallyincreasinglife
expectancythroughouttheindustrializedworld.Aspeoplelivelonger,thecomplicationsof
diabetes,peripheralvasculardisease,andotherchronicmedicaldiseasesprogressively
increasethefrequencyoflowerlimbloss.In1985,therewere112,500nontraumaticlower
limbamputationsintheUnitedStates,and50%ofthesewereinpatientswithdiabetes.
The3yearsurvivalrateafteramajoramputationfordiabetesorvasculardiseaseisabout
50%andisessentiallyunchangedfromthemid1960stotheearly1980s.Sincethese
diseasestatesaresystemic,studieshaveshownthatapproximately25%oftheoriginal
group,orabout50%ofsurvivingpatients,canbeexpectedtolosethesecondlimbby2to3
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yearsfollowingthefirstamputation.Thequalityofsurgical,medical,andrehabilitative
carefurtherresultsinalifeexpectancyofmonthsandoftenyearsasabilaterallowerlimb
amputee.Mobilitybyambulationwithprosthesesprofoundlyimprovesthequalityoflifeas
comparedwithawheelchairexistence.
Therearealsoanincreasingnumberofbilaterallowerlimbamputeesasaresultoftrauma,
especiallyinwarornaturaldisasters.Thecurrenthighqualityandavailabilityofmilitaryand
emergencymedicalcareallowssurvivalformanypatientswhoseseveretraumawouldhave
beenfatalinpreviousdecades.Lossofbothlowerlimbsisalsoencounteredintrauma
centersthroughouttheindustrializedworld.Motorcycleaccidents,pedestrianinvolvementin
carortrainaccidents,andsevereburnsaregenerallyresponsible.Mostofthosesustaining
bilateraltraumaticlowerlimbamputationsareadolescentsandyoungadults.Prosthetic
rehabilitationpotentialisusuallyexcellent.
Bilateralcongenitallegamputationsandlimbdeficienciesencompassasmallbutoften
difficultgroup.Withappropriateprostheticmanagement,rehabilitationcanbesurprisingly
successfulandrewardingintheseinfantsandchildren.Evenifprostheticambulationisnot
expectedtocontinueintoadultlife,theindependenceandmobilityachievedbyaggressive
prostheticrehabilitationintheearlyyearsimprovesthegeneralhealthandsocial
developmentofthesechildren.

SURGICALDECISIONMAKING
Retentionofmaximumlimblengthbyamputationatthedistalmostsuitablelevelis
particularlyimportantforthebilateralamputee.Thereisabsolutelynoaddedbenefitto
havingbothlowerlimbsamputatedatthesamelevel.Evenifapatientisabilateral
transtibialamputee,itisnotnecessarytohavebothlegssymmetrical,andalllength
possiblethatissuitableforprostheticfittingshouldbepreserved(Fig24A1.[1][1]).Stateof
theartplasticandmicrovascularreconstructivesurgeryisonoccasionjustifiedtomaintain
residuallimblength.Thisisparticularlytruewhentheamputationsresultfromburns.Bone
lengtheningprocedures,however,arerarelyjustified.Thesurgicalmanagementofthese
difficultcasesrequiresafullknowledgeoftheprinciplesofmodernprostheticmanagement.
Theamputationsitebecomesthenewinterfaceforhumancontactwiththeenvironment
andmustbeasfunctionalandcomfortableaspossible(Fig24A2.[2][2]).
Eveninthebilateralamputee,thereremainafewregionswhereitisnotadvisableto
amputate,notonlybecausehealingmaybecompromisedbutalsobecauseprosthetic
substitutionsareunsatisfactoryatthesefewlevelsinthelowerportionoftheleg.These
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areasincludethelowerfifthofthelegdowntobutjustabovetheSymelevelankle
disarticulation,theveryshort
transtibialamputationabovetheattachmentofthepatellartendon,andtheveryshort
transfemoralamputationinthesubtrochantericregion.Ineachoftheseinstancesitis
usuallybettertoelectamputationatahigherleveltopermitimprovedprostheticsubstitution
andpatientcomfort.
Althoughoptimumfunctionisusuallytheprimaryconcerninamputation,thecosmesisof
theprostheticlimbreplacementmustalsobeconsidered.Symeankledisarticulationand
kneedisarticulationlevelshaveabulbousendandresultinalessaestheticappearancein
thefinalprosthesis.Patientswithhighcosmeticexpectationsmightbedissatisfiedwith
theselevels(Fig24A3.[3][3]).
Inthegeriatricagegroup,thepatient'sactivitylevel,ambulatorypotential,cognitiveskills,
vision,andoverallmedicalconditionmustbeevaluatedtodeterminewhetherthedistalmost
levelisreallyappropriateforthepatient.Inambulatorypatients,thegoalistoachieve
healingatthemostdistallevelthatcanbeprostheticallyfitandallowsuccessful
rehabilitation.Mostunilateraltranstibialamputeeswhoweresuccessfulprosthetic
ambulatorswillmasterbilateralamputeegaitifatranstibialormoredistalamputationcan
beperformedonthecontralaterallimb.Thesuccessofrehabilitationdecreasesdramatically
iftransfemoralorhigherlevelamputationsneedtobeperformed.
Innonambulatorypatients,thegoalistoobtainwoundhealing,minimizecomplications,and
improvesittingbalance,transfers,andnursingcare.Forexample,abedriddenpatientwith
hipandkneeflexioncontracturesmightbebetterservedwithakneedisarticulationorvery
longtransfemoralamputationthanwithatranstibialamputation.Ontheotherhand,a
geriatricpatientwithaprevioustransfemoralamputationmightbeanonambulatorbutstill
haveexcellentindependenttransfersandbathroomskills.Ifthepatientcapableof
independenttransfersdevelopscontralateralfootgangrene,hemightbebestservedby
preservingallpossiblelengthandprostheticfitting,ifthegoalistocontinueindependent
transfersandbathroomactivities.Suchskillsareextremelyimportantinthebilateral
amputeeandshouldbegivencarefulpreoperativeevaluation,eveninnonambulatory
patients.Carefulpreoperativeassessmentofthepatient'spotentialandsettingrealistic
goalscanhelpdirectsurgicallevelselectionandpostoperativerehabilitationwisely.

PROSTHETICFITTINGANDREHABILITATION
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Rapidprostheticrehabilitationofthemultiplelimbamputeeensuresthebestresultsin
returningtoanactive,independentlifestyle.Speedofrecoveryisfrequentlyindicativeof
howwellthepatientwillbeabletoperformpredeterminedrehabilitationgoals.Thisis
particularlyimportantinthemanagementofthemajorityofamputeeswearetreatingtoday,
theelderly.Thepsychologicalandeconomicbenefitstothispatientapproacharealsoquite
appreciable.Contemporaryprostheticfittingofthebilaterallowerlimbamputeecanbe
categorizedintoimmediatepostsurgicalprostheticfitting(IPPF),earlypostsurgical
prostheticfitting,preparatoryprostheticfitting,anddefinitiveprostheticfitting.Although
manageddifferently,previousunilateralamputeeswholaterbecomebilateraland
simultaneousbilateralamputeesbothbenefitfromearlyrehabilitationwithcontrolledweight
bearing.
Improvedwoundhealing,thepreventionofcontractures,andearlymobilizationthroughthe
useofrigiddressingsdominatetheimmediateandearlyphases.Maturationofthe
residuallimbbycomfortably,increasingweightbearingandinitialgaittrainingpredominate
inthepreparatoryprostheticphase.Cosmesis,durability,andfinalgaittrainingbecome
importantconsiderationsinthedefinitiveprostheticphase.Increasedsophisticationof
currentfittingtechniques,materials,andavailablecomponentrymakethecorrectselection
andapplicationmorecriticalthaneverbeforeasthepatientsproceedthroughthesevarious
phasesofprostheticmanagementandtraining.
ImmediatePostsurgicalProstheticFitting
Ideally,IPPFwithcontrolledweightbearingistheinitialpatienttreatmentofchoice,
especiallyintheyoungtraumaticamputee.Thedetailsandbenefitsofapplyingarigid
dressing(i.e.,plasterofparissocket)withapylonextensionandprostheticfootinthe
operatingroomhavebeenadequatelydocumentedintheliterature.Theprimary
considerationisachievingrapid,optimalwoundhealing.Thisisaccomplishedbycontrolling
postsurgicaledemawithoutrestrictingcirculation.Tissuesupportminimizesinflammatory
reactionandreducesphantompain.Thepsychologicalbenefitsaresignificantasthepatient
wakesupwithaprosthesisinplaceoftheamputatedlimbandrehabilitationstarts
immediately.Carefullycontrolledstaticweightbearingcanbeinitiatedthefirstpostoperative
dayorwheneverthepatientisphysicallycapableoftoleratingtheprocedure.Useofatilt
tableisnecessaryforthebilateralamputee,withbathroomscalesorotherpressure
monitoringdevicesutilizedtohelpregulateweightbearing.Aswoundhealing
progressesandismonitoredatthevariouscastchangeintervals,weightbearing
incrementsarealsoacceleratedaccordingly.Actualambulationactivitiesaredelayeduntil
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theincisionshavehealedandsutureshavebeenremoved.Patientswithsimultaneous
bilateralamputationsmustbeadvancedmoreslowlyandcarefullythantheprevious
unilateralamputeewhocantolerateunrestrictedweightbearingonthemature,previously
amputatedlimb(Fig24A4.[4][4]).
Ifprostheticpylonshavenotbeenutilizedinitially,manuallyapplied,simulatedweight
bearingactivitiesareadministeredbythetherapistorthepatienthimselfthroughthecast
(Fig24A5.[5][5]).Thereductioninedemathatresultsfromsimulatedweightbearing
decreasespostoperativediscomfort.IPPFcanbeimplementedinanyhospitalsettingthat
hasatrainedteamofprofessionalsavailable.Theteamconsistsofasurgeon,aprosthetist,
aphysicaltherapist,anurse,andotherauxiliarypersonnelasmightberequired.
EarlyPostsurgicalProstheticFitting
Undercertainconditions,thesurgeonmaydeferapplicationofarigiddressing1to3weeks
postsurgicallytoornearthetimewhensuturesareremovedfromthesurgicalincision.
Althoughwepreferimmediateuseofrigiddressings,todelayuntilsutureremovalisvery
commoninthebilateralamputee.Atthisstage,considerablepostsurgicaledemaisusually
evident,andresiduallimborphantompaincanbeexaggeratedinspiteofsoftcompression
dressingssuchasanelasticbandageorshrinkersock.Inallprobability,thepatienthas
beenrestrictedtobedrestorlimitedtowheelchairmobility,whichleadstophysical
decompensationandmuscleweakness.Inaworstcasescenario,woundhealingcanbe
compromisedasaresultofthisdelay.
TheearlyprostheticfittingtechniquesemployedarethesameasfortheIPPF.If
considerableedemaisevidentattheinitialapplicationofthecastsocket,frequentcast
changesmaybeindicateduntilthisconditionstabilizes.Ifacastsocketinadvertentlycomes
offthelimb,itshouldnotbepushedbackon.Damagetotheresiduallimbmayresultwith
associatedpainforthepatient.Anewcastsocketmustbeappliedwithoutdelay.
Removablecastsockets,inourexperience,havebeenunsuccessful.Asthenameimplies,
theyareremovableandcancomeofftheresiduallimbatthemostinappropriatetime.
Theneedfordailywoundinspectioncontradictsourpositionofundisturbedtissuesupport
andimmobilization.Removablerigiddressingsmustbecontinuouslymonitoredandrequire
thecompletecooperationofareliablepatient.Regularintervalfullcastchangesbetween7
and10daysareadequatefordressingchangesunlesswoundproblemsrequiremore
frequentattention.
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Softcompressiondressingssupplementedbyanelasticbandageorshrinkersockareless
effectiveinachievingrapidwoundhealing.Residuallimbedemaassociatedwithdiscomfort
andphantompainisfrequentlyevidentwiththisformofpatienttreatment.Itdelaysthe
recoveryperiodunnecessarilyandinvitesfurthercomplicationsintheformofjoint
contracturesandgeneralphysicaldecompensation,especiallyinthegeriatricpatient.
PreparatoryProstheticFitting
Preparatoryprostheses,alsoreferredtoasintermediateortrainingprostheses,areusefulif
thevolumeoftheresiduallimbisexpectedtodecreaserapidlyinthenearfutureorifa
gradualreductionofjointcontractureswillrequirerepeatedprostheticrealignment.This
iscommoninsimultaneousbilateralamputeeswhocannotadvancetheirweightbearingas
quicklyasunilateralpatients.
Suchprosthesesarealsoindicatedforevaluatingapatientspotentialtosafelyambulateor
todemonstratetoapatienttheenergyandskillrequirementsassociatedwiththeuseof
prostheses.Ifusedinthiscontext,preparatoryprosthesesareindeedjustifiedandpresent
thebestdiagnosticandeconomictoolformeasuringapatient'smobilitycapabilities.The
bilateralamputeegreatlybenefitsfromthisapproach(Fig24A6.[6][6]).
Componentchoiceiscarefullyprescribedinconsiderationoftheparticularpatient'sneeds.
Likewise,theprostheticsocketconfigurationaswellasdesignanticipatesthepatients
requirementsandisthecriticalcontactpointofthehumananatomyandthemechanical
substitute.Patientcomfortwillmakethedecisivedifferencebetweenacceptanceand
rejectionoftheprosthesisandisthereforeahighpriority.
Wheneverpossible,thecomponentsofchoiceshouldbethesameasthoseanticipatedfor
thedefinitiveprosthesistominimizetheretrainingandrelearningrequired.Theeconomics
ofthispracticearerealisticandobvious.Itisfrequentlyprudenttoutilizedefinitivefootshin
kneecomponentsforthepreparatoryprosthesisandcarrythemoverintothedefinitive
device.Commerciallyavailable,prefabricated,adjustablesocketsmaywarrant
considerationinparticularsituationswhenintheopinionoftheteamthisapproachispref
erable.
DefinitiveProsthesis
Definitiveprosthesesaresometimeserroneouslycalled"permanent"or"final"prostheses.
Thesearemisnomerssinceallprostheseswearoutmechanicallyorrequirereplacement
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duetodeterioratingfit.
Neverbeforeinthehistoryofprostheticshaveprosthetistshadsomanysophisticated
materialsandcomponentsattheirdisposaltoservetheirpatientsbetterandmore
effectively.Highstrength,lightweightcomponentsmadefromtitaniumandcarbonfibers
combinedwithsocketsfabricatedwiththermoplasticmaterialsoracrylicresinsresultina
lightweightprostheticconstructionthatreduceenergyconsumptionduringambulation
activities.Improvedbiomechanicalfittingprinciplesandstaticanddynamictestsocket
procedurescombinedwithflexiblesocketconstructionfurtherenhancepatientcomfort
andacceptance.Radiographsorxeroradiographycanisolateorpinpointresiduallimbfitting
problems.Recentdevelopmentsincomputeraideddesignandcomputeraided
manufacture(CADCAM)openthedoortonewandexcitingpossibilitiestobetterservethe
multiplelimbamputee.Allthisdemandsgreaterknowledgeandskillsonthepartofnot
onlyprosthetistsbutalsotheentireclinicteam,whoareresponsibleforformulatingthe
prostheticprescription.
Individualpatientneedsvarygreatlyamonginfants,children,adolescents,adults,athletes,
andactiveandsedentarygeriatricamputees.Therearedifferentrequirementsbetween
malesandfemalesandimportantconsiderationstobemadeforvocationalandrecreational
activities.Parents,spouses,relatives,andfriendsofpatientsalsoplayanimportantrole
sincetheyinfluencepatients'expectationsandreactionstotheirprosthesesand
management.Eachnewpatientrequiresindividualassessmentandevaluationtodetermine
hisexactpersonalneeds.Whilemanyamputationlevelsaresimilarorthesame,the
individualpatientrequirementsarevastlydifferentandmustbeaccommodatedtobe
effectiveintheoverall,totalrehabilitationofthepatient.Apatientmustlearntowalkbefore
hecanexpecttorun,ifthisisevenphysicallypossible.
Bilateralamputationscanbeofanequallevelsuchasfoot,ankle,transtibial,knee
disarticulation,transfemoral,andhipdisarticulation,oranycombinationoftheabove.Since
itisthesurgeon'sintenttopreservealljointsandallusefullengthintheresiduallimb,the
prosthetistispresentedwiththechallengeofvariedamputationlevelcombinationswhere
prostheticdesignsmustinteracteffectively.

INFANTAMPUTEES
Whilestatisticallyaverysmallgroup,childrenwithcongenitallimbdeficienciespresent
majorchallengestotheentirerehabilitationteam.Dependingonthefullextentofthe
anomaly,infantsmayfacecontinuoustreatmentthroughouttheirlifetimetomanagethe
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disability.Earlydiagnosis,surgicalintervention,andprostheticfittinghavebeenadvocated.
Asaresult,infantsarebeingfittedwithlowerlimbprosthesesasearlyas8monthsofage
orwhentheyattempttoaccomplishaseatedoranuprightposition.
Evenhighlevelamputeesasaresultoflumbosacralagenesishavebeenfittedwith
speciallydesignedprostheses.Theinitialprostheticsocketextendstothethoraxfor
stabilizationtoallowanuprightpositionandcanbefitforsittingasearlyas4to6
months.Thesocketismountedonastableplatformtowhichcasterscanbemountedfor
mobility.Limitedambulationisaccomplishedintime,whenthesocketismountedona
swivelwalkerforselfinducedmobility.Followingbilateralhipdisarticulations,theprosthetic
socketiscombinedwithcosmeticallyenhancedthighshankfootcomponentsthatallow
sitting,standing,andsomelimitedambulationontheprinciplesofaswivelwalker.Often
thesepatientshavemultiplemedicalproblemsthatrequirecontinuedtreatmentand
monitoringandmayinterruptprostheticmanagement.
Miniaturized,commerciallyavailableprostheticcomponentsareverylimitedforinfants.This
requirestheprosthetisttodesignandcustomfabricatewhatisneeded.Someupperlimb
componentssuchasmanuallylockingelbowjointscanbeintegratedintolowerlimbinfant
prostheses.Sincestructuralstrengthrequirementsareveryminimal,plastictubingcanbe
utilizedinendoskeletaldesignsandresultsinverylightweight,cosmeticappliances.
Recentlywehaveswitchedtoaluminumtubingthatisfittedintoalargersizetubing,thus
allowingtelescopinglengthadjustmentsforgrowth.
Ourcurrent,typical,initialkneedisarticulationinfantprosthesesconsistofflexible
thermoplasticsocketsmountedinrigidframes.Thisallowsforsocketreplacementsdue
togrowthwithoutremakingtheentireprosthesis.Totalcontactsocketdesignsusingasock
interfacewiththeclassicalSilesianbandageoramodifiedversionthereofhasbeenthe
mostfrequentmethodofsuspension.Aminiaturizedversionofthetotalelasticsuspension
(TES)belthasalsoprovedtobeaneffectiveoption.Anysuspensionconsiderationsmust
resolvetheproblemsofdiapersandthusshouldbemoistureresistantandwashable.
Flexibleorrigidpelvicbandandhipjointsuspensionorshoulderharnesssuspensionis
seldomindicatedininfants.Inourexperience,itispossibletofitselectinfantswithtotal
contactsuctionsuspensionasearlyas18to24monthsofage.Thiseliminatesmost
auxiliarysuspensionneeds.Theprerequisiteisthatparentsbeabletoapplytheprosthesis
correctly.Morefrequentsocketreplacementsasaresultofsuctionsocketfittingsarenotas
significantasanticipatedandshouldnotbeadeterrent.Recently,theintroductionofthe
hypobaricsuspensionsystemhasprovidedanothersuspensionoption.Thesystemutilizes
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aprostheticsockthatisimpregnatedcircumferentiallyatthemidportionwithanarrowband
offlexiblesiliconethatformsaneffectivesealontheinnersocketwallandresultsinsocket
suspension.Thissystemisappropriateevenforinfants.
Theuseofstubbiesastheinitialprosthesisisrecommendedforallbilateralknee
disarticulationortransfemoralamputees,regardlessofage,whoareconsidered
candidatesforambulationandwholostbothlegssimultaneously.Stubbiesconsistof
prostheticsocketsmounteddirectlyoverrockerbottomplatformsthatserveasfeet.The
rockerbottomplatformshavealongposteriorextensiontopreventthetendencyforthe
patienttofallbackwardinitially.Theshortenedanteriorportionallowssmoothrolloverinto
thepushoffphase.Ashipflexioncontractureslessenandbalanceimproves,theposterior
rockerextensionscanbeshortenedaccordingly.Theuseofstubbiesresultsinloweringof
thecenterofgravity,andtherockerbottomprovidesabroadbaseofsupportthatteaches
trunkbalanceandprovidesstabilityandconfidencetothepatientduringstandingand
ambulation.Asthepatientsconfidenceandambulationskillsimprove,periodiclengthening
ofthestubbiesispermitteduntiltheheightbecomesnearlycomparablewithfulllength
prostheses,atwhichtimethetransitionisattempted.Kneecomponentsareusuallyomitted
forinfantssincestabilityandbalancearestilldeveloping.
Themajorityofinfants,children,andyoungadultswithbilateralkneedisarticulationor
transfemoralamputationscangeneratetheenergyrequiredtoambulatewhenwearing
stubbieswithoutneedingassistivedevicessuchascrutchesorcanes.Assistivedevices
maybeneededforsafetyandsupportoncethepatienthasaccomplishedthetransitionto
fulllengthprostheses.Suchassistivedevicesseverelycompromiseupperlimbfunctionand
shouldbeavoidedwherepossiblesincethisaloneisamajordeterrenttousingfulllength
prostheses.
Parentslikecosmeticallypleasingprostheses,andeveryeffortshouldbemadetoachieve
thiswithoutsacrificingcomfortorfunction.Lightweightexoskeletaldesignsarealsoquite
acceptableforuseininfants,andthechoiceshoulddependonwhatisconsideredmost
appropriateforaparticularpatientandparent.

CHILDAMPUTEES
Mostchildren,includinghighlevelbilaterallowerlimbamputees,haveveryhighphysical
activitylevels.Theyareencouragedtoparticipateinplay,sports,andrecreationactivities
likeanyotherchild.Asaresultmanyofthechildrenplaceprofoundphysicaldemandson
theirprostheses.Prosthesesinneedofmajorservicingandrepairsareajoytotheentire
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clinicalteam,fortheydenoteaveryactive,welladjustedchildwhoisusingtheprostheses
totheirmaximumpotential.Forthisreason,durabilitymustbeconsideredinthedesignfor
thisactivegroupofamputees.Fortunately,withtheintroductionofnewpetrochemical
basedmaterialsthatarelightweightandstrong,thechallengeofprostheticdurabilitycanbe
metbettertodaythaneverbefore.Prostheticresearchers,engineers,suppliers,and
manufacturershavefinallystartedtomeetthechallengeofprovidingcomponentryforthis
veryactivegroupofyoungchildren.Somenoteworthyexamplesofthesenew
developmentsarethehipdisarticulationandtransfemoralendoskeletalsystemwith
adjustablekneefrictionandextensionassistfromOttoBockandtheChildPlaySeattle
LightFootfromM.I.N.D.TheAquaFlex,anallplastictransfemoralpediatrickneeshinsetup
fromFordLaboratoriesinRichmond,BritishColumbia,Canada,canbeusedtomakea
waterproofprosthesis.Manycomponentsarestillcustomdesignedandhandfabricatedby
prosthetiststomeettheirindividualpatientsneeds.
Comfortandcontroloftheprosthesisaredirectlyproportionaltogoodsocketretentionon
theresiduallimb.Thisbecomescriticalinthebilateralamputee.Thus,itisadvisableto
usesuctionsuspensionwheneverthisispossibleinbothtransfemoralandtranstibial
fittings.Theneedforslightlymorefrequentsocketreplacementsisasmallpricetopayto
allowimprovedfunctionandcomfortfortheactiveyoungster.
Theuseofthesiliconesuctionsocket(3S)techniquehasbeenreportedandexpandedto
includealllevelsofamputation.Hypobaricsuspensioncanalsobeutilizedinchildren,
aswellastheconventionalsuspensionsystemssuchashipcontrolbelts,waistbelts,and
cuffsuspensions.Unstablekneejointsmayrequiretheadditionofsidejointsandthigh
lacersor,ataminimum,apatellartendonsupracondylar(PTS)socketdesign.PTS
socketconfigurationisalsousefulforshortandveryshortresidualtranstibiallimbsand
wherepistoningmustbeheldtoaminimum,suchasinskingraftorburnpatients.Whatever
systemischosen,itmustfilltheneedsandabilitiesofthepatientandparentswithout
makingittechnicallytoocomplexandthusfrustrating.
OccasionallyapatientwithbilateraltibialhemimeliaisencounteredafterbilateralSyme
ankledisarticulationortranstibialamputations.Kneeinstabilityandflexioncontractures
aremajorconcernsthatfrequentlyaccompanythesecongenitallimbdeficiencies.Prosthetic
prescriptionshouldincludesidejointsandthighlacers,notsomuchtodistributeweightas
toprovideincreasedmediolateralkneestability(Fig24A7.[7][7]).Whenthekneeflexion
contractureexceeds15to20degrees,specialsocketmodificationsandtechniquesare
indicatedtoaccommodatethedeformity(Fig24A8.[8][8]).Ifthecongenitallimbdeficiencyis
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soseverethatkneeinstabilityorflexioncontracturesprohibitprostheticfitting,thenknee
disarticulationisrequiredononeorbothlimbs(Fig24A9.[9][9]).
Asdiscussedintheinfantsection,theuseofstubbiesastheinitialprosthesesis
recommendedforrehabilitationofallbilateralkneedisarticulationandtransfemoral
amputeeswhoareconsideredcandidatesforambulationandwholosttheirlegs
simultaneously.Themajorityofchildrenwithbilateralkneedisarticulationand
transfemoralamputationscangeneratetherequiredenergytodevelopambulatory
capabilitiesbyusingstubbieswithoutassistivedevicessuchaswalkers,crutches,orcanes
(Fig24A10.[10][10]).Thishighperformancelevelisnotalwayssustainablethrough
adulthood,butdiminisheswithadvancingagewhensomebecomemarginalusersor
abandontheprosthesesaltogether,exceptforcosmeticuse,infavorofwheelchairmobility.

ADOLESCENTANDYOUNGADULTAMPUTEES
Thisgroupofamputeesfrequentlyprovestheprostheticteamwrongwhentoldofphysical
limitationsassociatedwithmultipleamputations.Thenewsmediaconstantlyremindusof
thestunningaccomplishmentsofamputeeathletes,includingbilateralhighlevellowerlimb
amputees.Theserunners,swimmers,skiers,rowers,mountainclimbers,basketballplayers,
etc.,demonstratethedangersofstereotypingamputeeswithoutdatedclassifications.
Experiencehasprovedthatpatientscanexcelsafelyifgiventheopportunityratherthan
beingtoldthattheyareunabletodoso(Fig24A11.[11][11]).
Mostbilateralamputeesperformtheseextracurricularrecreationalactivitieswith
conventionalprostheses.Afew,morecompetitiveamputeeathletesmayhavespecial
prosthesesdesignedtoaidtheiraccomplishmentsincompetitivesportsevents.Thereisan
abundanceofmaterialsandcomponentryavailablefromwhichtoselectwhatismost
suitableforaparticularamputee.Theyshouldbeallowedtoevaluatedifferentsocket
designs,kneecomponents,andfeettodeterminethebestfunctionalcombinationfortheir
needs.Thisisanexpensiveandtimeconsumingprocessbutensuresthebestresults.
Similarly,refinementsofsocketfitthroughrepeatedstaticanddynamictestsocket
procedures,includingproperalignmentofcomponents,makesformorefunctional
prostheses(Fig24A12.[12][12]).
Suctionsuspension,includingsemiflexibletranstibialandtransfemoralsockets,ispreferable
forbilateralamputees,solongastheamputeeisabletodonanddofftheprostheses
effectivelywithoutassistance.Flexiblebrim,ischialcontainmenttransfemoralsockets
providemorecomfortduringambulationandwhenseatedbyprovidingincreasedclearance
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intheperineum.Itmustbenoted,however,thattherearenumeroussuccessfulbilateral
transfemoralamputeesutilizingquadrilateralormodifiedquadrilateralsuctionor
semisuctionprostheses.Eitherthesepatientshavenotyetmadethetransitiontoischial
containmentsocketdesigns,ortheyhavetriedthetransitionbutprefertoremainwiththeir
previoussocketdesigns(Fig24A13.[13][13]).
Earlyflexibleinnersocketslackeddurability.Surlynandcertainpolyethylenescrackedand
buckledunderrigoroususeandrequiredfrequentreplacement.Improvedworking
techniquesandbettermaterialshavereducedtheseproblemsandgiventheprosthetista
widerchoiceofoptions.The3Ssocketdesign,includingtheIcelandicRollonSuction
Socket(ICEROSS)system,providesexcellentsuspensionandminimizestheproblemof
excessiveperspirationoftheresiduallimbsthatiscommonlyencounteredinbilateral
prosthesisuse.
Dynamicresponsefootandanklecomponentshaveaprofoundimpactonsocketcomfort
andthefunctionalcapabilitiesofalllowerlimbprostheticusers.Amputeeshavenoted
improvementinproprioceptivefeedbackimprovednegotiationofinclines,declines,and
uneventerrainaswellasimprovedimpactabsorptionandreductionoftorqueandshear
forces.Alloftheseenhancestabilityandcontrolofprosthesesandimprovegait.Special
footalignmentandresistanceisrequiredforthebilateralamputeeforsecurityandbalance.
Thereisanabundanceofkneejointcomponentsavailablethataidinstabilityandfunction.
Formaximumdurability,exoskeletaldesignhastheadvantageoverendoskeletal
systems.Forcosmeticappearance,theendoskeletalsystemhasadistinctadvantageand
isthereforefavoredbymanyfemales.Postfittingrealignmentproceduresareperformed
muchmoreconvenientlyandexpedientlywithendoskeletaldesignsthanwithexoskeletal
systemsthatrequiremajorlaborintensivereworkingprocedurestoachievealignment
corrections.
Bilateralyoungtranstibialamputeesusuallybecomeexcellentambulatorswitharelatively
normalgaitwithouttheuseofexternalaids.Similarly,personswithbilateralpartialfoot
amputations,Symeankledisarticulations,oracombinationoftheselevelsaccomplisha
nearnormalgait.Kneedisarticulationortransfemoralamputeeswithcontralateraltranstibial
ormoredistalamputationalsobecomeaccomplishedambulatorsbutfrequentlyprefera
caneorotherassistivedevice.Mostbilateralamputeeswhohavelostonekneelimittheir
dailyambulationactivitiesandhavesedentaryjobs.
Thesimultaneouslyacquiredbilateralkneedisarticulationortransfemoralamputeerequires
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fittingwithstubbiesastheinitialprostheses,aspreviouslydiscussed.Inourexperience,
mostadultswithacquiredbilateraltransfemoralamputationsfailtobecomeconsistent
wearersoffulllengthprosthesesbutcontinuetheuseofstubbiesfortheirdailyambulation
activities.Theymayelecttowearthefulllengthprosthesesforspecialeventsorcosmetic
reasonsonly.Thelongerleverarm,balancedthighmusculature,andendbearingcapacity
ofthekneedisarticulationmakesbilateralfulllengthprostheticuseeasierthanforthe
bilateraltransfemoralamputee,buttheprinciplesandtrainingareverysimilar(Fig24A14.
[14][14]).Theaccomplisheduserofbilateraltransfemoralprosthesestypicallyusesacane
andhasmidthighorlongeramputationlevels.Thispatientwasusuallyinvolvedin
recreationalorsportsactivitiespriortotheamputations,isphysicallyslimandfit,andhas
highenduranceandgoodmotivation.Fulllengthprosthesesareusuallydesignedtoshorten
thepatient'sstatureslightlybecausebalanceisimprovedbyloweringthecenterofgravity
(Fig24A15.[15][15]).Useofastancecontrolormanuallockingkneeisreservedforthe
shorteroftheresiduallimbs.Differentkneemechanismscanandshouldbeutilizedas
required,buttheymustbetestedandevaluatedduringtrialambulation.Footandankle
componentsshouldbeofthesametypeandfunctionforbothlimbsandhaveastiffer
plantarflexionresistancethanisrequiredinunilateralcases.Largerfootsizemayimprove
supportandstability.Thepatientmustbeabletoachieveaseatedandstandingposition
independentlyandinlessthanideallocations.Theamputeemustalsobetrainedtoreturn
tothestandingpositionfromthegroundasoccasionallywouldberequiredafterafall.
Bilateraltransfemoralprostheticusersrequireagreatdealofgaittrainingbyaqualified
physicaltherapist.Negotiationofstairs,inclines,declines,anduneventerrainarecomplex
challengesthatmustbelearnedandpracticedbythepatienttobecomeanaccomplished
ambulator(Fig24A16.[16][16]).
Therearesomepossiblevariationsintherockerbottomsofstubbies.TheuseofSACH
feetwiththetoespointingposteriorlyhasbeenadvocatedbysomeforasmoothergait.We
haveutilizedrockerbottomsincorporatingtheGreissingerfootmultiaxialanklesystem(Fig
24A17.[17][17])andmorerecentlytheFlexWalkFootfittedtotennisshoes.Onetriple
amputeewithaveryshorttransfemoralamputationononesideiscapableofbrisklywalking
2milesdailyforexercise.Heprefersstubbiesoverfulllengthprostheses,whichrequire
muchhigherenergyoutput,arecumbersome,slowhimdown,andinstillaconstantfearof
falling(Fig24A18.[18][18]).Thisexperienceisverycommonwiththeuseoffulllength
transfemoralprosthesesandrestrictsthemajoritytoambulationwithstubbiesonly.
Adultswithacquiredbilateralhipdisarticulationrarelybecomeeffectiveambulators,butthey
stillmayrequestspecialpurposeprostheticfittings.Speciallydesignedandfittedsocketsto
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allowformorecomfortableseatingcanbeprovided.Fulllengthfunctionalprosthesesare
primarilyforcosmeticappearancewhileseatedinawheelchair,butitispossibleforthe
patienttostandintheseprosthesesandinitiatevoluntarymobilityontheprinciplesofa
swivelwalker.Aparticularlystrongpatientcanalsoaccomplishaswingthroughgaitwith
theaidofcrutches(Fig24A19.[19][19]).

GERIATRICAMPUTEES
Thegreatmajorityofbilaterallowerlimbamputeestodayaretheelderlywholosetheir
limbssecondarytodiabetesandvasculardiseasebetweentheagesof55and95years.In
general,dismissingthesepatientsaspoorprostheticcandidatesisagravemistakeand
compromisestherehabilitationpotentialwhenimmediatepostsurgicaltreatmentisdelayed.
Lackofexerciseandmobilitywillencouragejointcontractures,weakenthepatient,cause
lossofindependence,bringondepression,andmayevenbecomelifethreatening.No
patientgroupbenefitsmorefromimmediatepostsurgicalprostheticfitting,includingearly
fittingofpreparatoryordefinitiveprostheses,thanthegeriatricbilateralamputee.The
challengeofrehabilitatingthesepatientsisfrequentlycomplicatedbythepresenceofother
illnesses.Diabetes,chronicinfection,kidneydisease,cardiovasculardisease,respiratory
disease,arthritis,andimpairedvisionarecomplicatingfactorsthatrequirecareful
considerationwhenevaluatingpatients.Delayedwoundhealing,slowlyhealinglesions,and
neuropathywarrantadditionalconsideration.Ofthesecomplicatingfactors,diabetes
appearstobetheleadingcauseofsecondlimbloss.
Fortunately,thetimeintervalbetweenthefirstandsecondlimbloss,whichcanbemonths
orperhapsyears,makeslearningtoambulateeasierforthepatientthanifbothlimbsare
lostsimultaneously(Fig24A20.[20][20]).Chronologicagealoneshouldnotdetermine
whetheranamputeeisaprostheticcandidate.A90yearoldpatientcanbeinbetter
physicalshapethana50yearoldanduseprosthesesaccordingly.Whilethepatient
mustbeabletounderstandandfollowinstructionsforproperuseoftheprosthesis,thismay
notbealwaysthecaseimmediatelyprecedingorfollowingamputationwhensystemic
toxicityfromaninfectedlimbmaycausethepatienttoacttemporarilyconfusedorunaware
oftheongoingproceedings.Sometimespatientsarewronglydiagnosedasprosthetic
noncandidatesanddeniedprostheses.Wemustgivethepatientthebenefitofthedoubt
andprovideatleastpreparatoryprosthesestoevaluateambulationpotential.Evenif
prosthesesareusedonlytoassistintransferactivities,theyarejustified.
Preoperativeandpostoperativepatienteducationisanimportantadjuncttorehabilitation.
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Teachingapatientproperhygieneandcareoftheresiduallimbsandtheprosthesesisvital.
Amputeesupportgroups,nowavailableinmanylocalities,areagreatbenefittopatientsin
learningabouttheirdisabilityandinbeingabletodiscussmatterswithotheramputeesthat
theymaybereluctanttodiscusswithclinicteammembers.Olderpatientsrequiremuch
moretime,understanding,patience,andencouragement.Theythriveonpraise,andeven
smallimprovementsgiveencouragementandaidinprogress.Theyarefrequentlyforgetful
andneedtobereinstructedfrequently.Spousesandotherfamilymembersshouldbe
encouragedtoparticipateduringfittingandtrainingsessions.Theirinputisimportant,and
theirconcernsshouldbeaddressedindetail.
Prosthesisdesignandcomponentrymustbebasedoncarefulindividualevaluationofall
pertinentfactors.Themostsophisticatedprosthesiswithhydraulicorpneumaticswing
phasecontrol,rotatorsortorqueabsorbers,andenergystoringfootistotallyinappropriateif
wearedealingwithamarginalambulatorwhousestheprosthesisonaverylimitedindoor
basis.Anytypeofprosthesisisinappropriateifthepatientisunabletodonanddoffit
properly.Bilateraltransfemoralprosthesesaretoodifficulttomanageformostgeriatric
patientsand,ifrequested,areprimarilyforcosmeticeffectwhileusingawheelchair.Even
stubbiesareoftentoodifficultforthisgrouptomaster,anditisaveryrareexceptiontofind
someonewillingtotryandtosucceedinambulatingwiththemregularly(Fig24A21.[21][21]).
Useofatransfemoralandtranstibialprostheticcombinationislimitedtoonlyafewvery
energeticpatientsandthenforonlylimitedusearoundthehouse.
Socketdesignmustbesuchthatthepatientcandonanddofftheprosthesisindependently.
Fortranstibialprostheses,thismayrequirethatspecialpullonloopsbeattachedtothe
socketorlinerforpatientswitharthritisofthehands.Similarly,apatientmustbeableto
properlyinstallawedgesuspensionsysteminaPTSdesign,orotheralternativesmustbe
utilized.Aneoprenesuspensionsleeveisanexcellentmeansofauxiliarysocket
suspensionifthepatientcanapplyitproperly.Ifthepatientcannothandlebuckles,Velcro
closuresshouldbesubstituted.Sidejointsandthighlacersareinfrequentlyrequiredforan
unstablekneeorveryshortresidualtranstibiallimb.Theygreatlycomplicatedonningthe
prosthesis,andshouldbeavoidedifotheralternativesexist.Littlefrustrationscanleadto
totalrejectionoftheprosthesesandmustbeavoided.Thebasicruleistokeepthemas
simpleaspossible.
Althoughsuctionsocketsuspensionisthepreferredmeansofsuspension,thebilateral
geriatricamputeecanseldommastertheconventionaldonningtechnique.Analternative
methodthatmeritsconsiderationisuseoftheliquidpowder,wetfitmethod,inwhichthe
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patientliberallyappliesaspecialliquidlubricantthatallowsdonningtheprosthesis.This
lubricantrapidlydriesintoapowderthatallowsretentionofthesocketbysuction.Another
optionistoprovideflexible,rollonsiliconelinersthatallowdonninganddoffingwhile
seated.Hyperbaricsocketsuspensionoffersanotherexcellentoption.
Themajorityofbilateralgeriatrictranstibialamputeesmasterambulationwiththeaidofa
walkerorcane.Anamputeewithtranstibialamputationandamoredistallevelonthe
contralateralsidealmostroutinelyachievesambulatorystatuswithorwithoutawalkingaid
(Fig24A22.[22][22]).Prosthesesforgeriatricamputeesshouldbemadeaslightaspossible
withcontemporarytechniques.Theyshouldbeofrelativelysimpledesignandnotcontain
superfluouscomponentsthatmaybeofquestionablebenefittolimitedambulators.
Occasionallygeriatricpatientswithbilateralcongenitaldeformitiesareencounteredwho
haveremainedactiveambulators.Fortheserarepatients,customdesignedprosthesesare
required.Lightweightconstructioncanprolongprostheticuseandambulation(Fig24A23.
[23][23]).

SHOESFORAMPUTEES
ItisnoteworthythatKegelreportstherecentdevelopmentofspecialdressshoesfor
amputeesthatareverylightweight,flexible,andhaveasoftcompressibleheeltodampen
impactatheelstrike.TheshoesaremanufacturedbyBallyandlooklikeanyotherregular
dressshoe.Kegelstatesthat"thereareshoesavailableforsoccer,tennis,skiingandother
specialrequirements,butnoneforprosthesesusers."Thisnewdevelopmentremediesthis
need.

SUMMARY
Thebilaterallowerlimbamputeepresentscomplicatedproblemsformobilityand
ambulation.Thetremendousdevelopmentsofrecentyearsoffertheseindividualsmuch
greaterfunctionalpotential.Byapplyingthesurgical,prosthetic,andrehabilitation
techniquescurrentlyavailable,thebilaterallowerlimbamputeecanoftenachievea
remarkabledegreeoffunctionalambulation.
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Chapter24AAtlasofLimbProsthetics:Surgical,Prosthetic,andRehabilitationPrinciples

References
1. ^Fig24A1.(www.oandplibrary.org)
2. ^Fig24A2.(www.oandplibrary.org)
3. ^Fig24A3.(www.oandplibrary.org)
4. ^Fig24A4.(www.oandplibrary.org)
5. ^Fig24A5.(www.oandplibrary.org)
6. ^Fig24A6.(www.oandplibrary.org)
7. ^Fig24A7.(www.oandplibrary.org)
8. ^Fig24A8.(www.oandplibrary.org)
9. ^Fig24A9.(www.oandplibrary.org)
10. ^Fig24A10.(www.oandplibrary.org)
11. ^Fig24A11.(www.oandplibrary.org)
12. ^Fig24A12.(www.oandplibrary.org)
13. ^Fig24A13.(www.oandplibrary.org)
14. ^Fig24A14.(www.oandplibrary.org)
15. ^Fig24A15.(www.oandplibrary.org)
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17. ^Fig24A17.(www.oandplibrary.org)
18. ^Fig24A18.(www.oandplibrary.org)
19. ^Fig24A19.(www.oandplibrary.org)
20. ^Fig24A20.(www.oandplibrary.org)
21. ^Fig24A21.(www.oandplibrary.org)
22. ^Fig24A22.(www.oandplibrary.org)
23. ^Fig24A23.(www.oandplibrary.org)
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READABILITYAnArc90LaboratoryExperimenthttp://lab.arc90.com/experiments/readability

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